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Emergency liver resection for ruptured hepatocellular carcinoma complicating cirrhosis
A Chiappa1, A Zbar, R A Audisio
1Department of Emergency Surgery, Milan University, H. S. Raffaele IRCCS, Italy. chiappa.antonio@hsr.it
Insights
Emergency liver resection for ruptured hepatocellular carcinoma (HCC) in patients with cirrhosis is feasible. Surgical resection offers the best chance for long-term survival, especially in patients with preserved liver function.
Area of Science:
- Hepatobiliary Surgery
- Surgical Oncology
- Gastroenterology
Background:
- Spontaneous rupture of hepatocellular carcinoma (HCC) in patients with cirrhosis is a rare but life-threatening complication.
- This study focuses on the management of 6 patients who presented with acute hemoperitoneum due to ruptured HCC and underwent emergency hepatectomy.
Purpose of the Study:
- To report the experience of emergency liver resection for ruptured HCC complicating cirrhosis.
- To evaluate the feasibility and outcomes of surgical management for this critical condition.
Main Methods:
- Pre-operative diagnosis of hemoperitoneum was confirmed using ultrasound and paracentesis.
- Hepatic functional reserve was assessed using Child-Pugh classification to determine operative risk.
- Emergency liver resection (segmentectomy or non-anatomical wedge resections) was performed based on hemodynamic instability or persistent bleeding.
Main Results:
- No intra-operative deaths occurred.
- Four patients had an uneventful post-operative course.
- Two patients died within two weeks due to liver failure, one complicated by renal failure. Three patients survived, with two disease-free at 24 months.
Conclusions:
- Emergency liver resection is a feasible option for ruptured HCC in patients with preserved liver function (Child-Pugh A or B).
- Surgical resection is the only approach associated with potential long-term survival.
- Conservative management may be considered for high-risk patients, but long-term survival data are lacking.
Background/Aims:
From a consecutive series of 51 patients surgically treated from January 1993 to August 1997 for hepatocellular carcinoma (HCC) complicating cirrhosis, 6 subjects (12%) presented with acute hemoperitoneum due to spontaneous rupture of the tumor: 3 patients were suffering from chronic hepatitis C, 2 were affected by alcoholic cirrhosis, and one by chronic hepatitis B. The present paper reports experience of the treatment of ruptured HCC complicating cirrhosis in 6 patients undergoing emergency hepatectomy.
Methodology:
Hemoperitoneum was successfully diagnosed pre-operatively with the combination of abdominal ultrasound (US) and paracentesis. All subjects had a known history of chronic liver disease, but undiagnosed HCC. Child-Pugh classification assessed the hepatic functional reserve to predict operative risk. Surgical indication was based on hemodynamic instability and/or persistent bleeding. Time from admission to operation was recorded as well as tumor site, size and number, the site of bleeding, and the duration of surgery and hepatic devascularization. Tumor location was defined according to segmental anatomy. All patients underwent one-stage liver resection (segmentectomy VII-VIII in one patient; non-anatomical wedge resections in 5). Operative mortality was defined as death within 30 days of surgery.
Results:
No intra-operative death occurred. In 4 patients the post-operative course was uneventful. Two patients died 2 weeks after surgery from liver failure (one patient) eventually complicated by renal failure (one patient). Three patients are alive and 2 of them disease-free at 24 months after surgery, whilst one patient has died from liver failure 21 months after surgery in the presence of intrahepatic recurrence of HCC.
Conclusions:
Present experience, combined with a literature review on 755 ruptured HCC cases, indicates that emergency liver resection is feasible in patients with limited tumor and preserved liver function (Child-Pugh A or B grade); surgical resection is the only procedure possibly associated with long-term survival, as shown by 4/6 patients of ours surviving more than 12 months, with 2 subjects disease-free at 24 months. Conservative management, such as surgical/radiological devascularization, packing or plication, can be conducted on high risk patients, though long-term survivors have not been reported.